Tex.
Ins. Code Section 1575.172
Out-of-network Facility-based Provider Payments
(a)
In this section, “facility-based provider” means a physician or health care provider who provides health care or medical services to patients of a health care facility.(b)
Except as provided by Subsection (d), the administrator of a managed care plan provided under the group program shall pay for a covered health care or medical service performed for or a covered supply related to that service provided to an enrollee by an out-of-network provider who is a facility-based provider at the usual and customary rate or at an agreed rate if the provider performed the service at a health care facility that is a participating provider. The administrator shall make a payment required by this subsection directly to the provider not later than, as applicable:(1)
the 30th day after the date the administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or(2)
the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator to pay the claim.(c)
Except as provided by Subsection (d), an out-of-network provider who is a facility-based provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee receiving a health care or medical service or supply described by Subsection (b) in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee’s managed care plan that:(1)
is based on:(A)
the amount initially determined payable by the administrator; or(B)
if applicable, a modified amount as determined under the administrator’s internal appeal process; and(2)
is not based on any additional amount determined to be owed to the provider under Chapter 1467 (Out-of-network Claim Dispute Resolution).(d)
This section does not apply to a nonemergency health care or medical service:(1)
that an enrollee elects to receive in writing in advance of the service with respect to each out-of-network provider providing the service; and(2)
for which an out-of-network provider, before providing the service, provides a complete written disclosure to the enrollee that:(A)
explains that the provider does not have a contract with the enrollee’s managed care plan;(B)
discloses projected amounts for which the enrollee may be responsible; and(C)
discloses the circumstances under which the enrollee would be responsible for those amounts.
Source:
Section 1575.172 — Out-of-network Facility-based Provider Payments, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1575.htm#1575.172 (accessed Jun. 5, 2024).
